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Gravitational Effects
Improper body alignment limits function, and thus it is a concern of
everyone regardless of occupation, activities, environment, body type,
sex, or age. To effectively overcome postural problems, therapy must
be based upon mechanical principles. In the absence of gross
pathology, postural alignment is a homeostatic mechanism that can be
voluntarily controlled to a significant extent by osseous adjustments,
direct and reflex muscle techniques, support when advisable,
therapeutic exercise, and kinesthetic training.
In the health sciences, body mechanics has often been separated from
the physical examination. Because physicians have been poorly
Posture Analysis
It has long been felt in chiropractic that spinal subluxations will be
reflected in the erect posture and that spinal distortions result in the
development of subluxation syndromes. Consequently, an array of
different methods and instrumentation has been developed for this
type of analytical approach such as plumb lines with foot positioning
plates to allow for visual evaluation relative to gravitational norms,
transparent grids, bubble levels, silhouettographs, posturometer
devices to measure specific degrees in attitude, multiple scale units to
measure weight of each vertical half or quadrant of the body, and
moire contourography.
During normal walking, one leg is in the stance phase while the other
isin the swing phase. Muscles must contract to counterbalance the
forces of gravity, to offer acceleration or deceleration to momentum
forces, and to overcomethe resistance of the walking surface.
The Stance Phase. About 60% of the walking cycle is used in the
stance phase. Because the stance phase is the weight-bearing phase
requiring the greatest stress, most problems will become apparent in
its analysis. The stance phase is subdivided into:
(1) heelstrike,
(2) footflat, and
(3) toe pushoff.
Midstance is that weight-bearing period between footflat to toeoff. The
duration of gait is usually measured from heelstrike to heelstrike, but
any two identical points can be taken.
The Swing Phase. This is subdivided into:
Examination of Gait
Every person has a gait, or manner of progressive locomotion, which is
peculiar to that individual. However, there are also various modes of
walking peculiar to certain diseases which are important diagnostic
clues. The range of movements in the lower extremities assists in
recognizing specific diseases and helps the doctor of chiropractic
determine postural changes resulting from an unnatural gait. For
instance, a shortened leg gives a characteristic limp. A stiff knee
causes the affected limb to swing outward while walking. Intermittent
claudication or limping is observed in chronic peripheral vascular
diseases such as endarteritis because muscular activity requires more
blood than muscular inactivity.
As the walking gait is the most fundamental form of dynamic posture,
it should form the basis of holistic biomechanical analysis. In health,
most locomotive adjustments are conducted at an unconscious level.
This is not true with the patient suffering a neuromusculoskeletal
disability affecting gait. Every motion may require a frustrating
conscious effort such as that taken by a healthy person stepping into
a canoe where the support is unfamiliar.
Although children emulate adult gait in many respects, there are
differences that must be considered in analyzing a pathologic or
functionally impaired gait during childhood. Foley and associates,
utilizing a TV-computer system of data gathering and analysis, found
that joint-angle ranges were the same in children as those of
adults.5(155)4 However, accelerations, velocities, and linear
displacements were consistently larger for children aged from 6 to 13
years (mean value 10.2) than were adult values.
FOOTFLAT
Inspection. In weight bearing, the pelvis rotates on its vertical axis,
the femur rotates on the pelvis, and the tibia rotates laterally on the
femur.
Mechanisms. During footflat, maximum stabilization of the foot
occurs during stance when body weight is directly above the foot.
Forward momentum eliminates the need for active hip and ankle
flexion or extensor stabilization, but there is some knee flexion by
quadricep contraction. When body weight is placed on the stance side,
the plantar flexors of the foot contract to counterbalance the reactive
force of the walking surface which forces the foot into dorsiflexion up
to 15 at heeloff, and the adductors of the hip contract to
counterbalance the pelvic adduction resulting from pelvic tilt.
MIDSTANCE
Inspection. At midstance, the head and trunk are vertical with the
arms near the midline of the body and at an equal distance from the
body. The elbows are partially flexed. On the weight-bearing side, the
pelvis is rotated slightly anterior, the knee is in slight flexion, the leg is
in slight lateral rotation at the hip, and the ankle is in slight
dorsiflexion. There is a downward pelvic tilt on the contralateral side
(Fig. 4.26).
Mechanisms. Following full vertical weight bearing, the line of
gravity moves forward on the stabilized plantar surface to produce a
reactive force which contributes to ankle, knee, and hip extension. Hip
extension reaches about 15 at the time of heeloff. This takes place
without any active extensor muscle action, but some stabilization
effect occurs by the iliopsoas. During this process, the gravity line
falls anterior to the knee so that quadriceps action is no longer
necessary. The ground reaction moves from the midfoot to the forefoot
as toeoff approaches which increases the moment of dorsiflexion. In
reaction, plantar flexion contraction peaks at heeloff to drive the body
forward. While this tends to extend the knee, full extension is
restricted by the gastrocnemius --an ankle and knee flexor.
Energy Absorption. During gait, peak activity of the joints of the
lower extremity is reached during the period of double support. At this
period, the knee muscles are absorbing energy while the other joints
are producing energy. As the hamstring group and gastrocnemius are
two-joint muscles, much of this energy can be transferred to produce
energy at other joints.
PUSHOFF
Inspection. On the side of pushoff, the arm is anterior to the
midline of the body and the elbow is partially flexed. On the
contralateral side, the arm is posterior, the elbow is slightly extended.
Both arms are equally distant from the body. On the side of pushoff,
the femur is slightly rotated laterally at the hip, the knee is slightly
flexed, the ankle is plantar flexed, and the toes are hyperextended at
the metatarsophalangeal joint. The plantar surface of the heel and
midfoot should become visible from the posterior during pushoff (Fig.
4.27).
Mechanisms. The later part of stance occurs between heeloff and
toeoff and provides the major portion of forward and vertical
propulsion force. The hip adductors and iliopsoas begin to contract in
anticipation of the swing phase, but most action occurs at the ankle
and knee. The ankle changes from about 15 dorsiflexion at heeloff to
about 35 plantar flexion at toeoff, and the extended knee flexes to
about 40 as the quadriceps contract. At toeoff, the segments begin to
reverse the lateral rotation attained during footflat, and this medial
rotation of the pelvis, thigh, and leg continues to 2035, depending
on walking speed, until the next footflat is reached. Once the toes
leave the ground, hip and calf muscles relax.
ACCELERATION
Inspection. The period of acceleration of the advancing leg occurs
during the first part of the swing phase when the limb is between
toeoff and midswing. The swing phase involves almost simultaneous
hip flexion, knee flexion, ankle dorsiflexion, and usually a concomitant
forward swing of the hip that rotates the pelvis contralaterally to some
degree.
Mechanisms. The primary forces are generated by the hip flexors
and ankle dorsiflexors. Hip flexion is governed by the tensor fasciae
latae, the pectineus, and the sartorius. The most powerful hip flexor,
the iliopsoas, and the adductor magnus are not active during swing,
according to electromyographic evaluations. Knee flexion is aided by
sartorius contraction, gravity, and passive pull of the posterior
hamstrings. The flexion of the knee after toeoff is passive while the
thigh accelerates forward from action by the hip flexors. As the hip
and knee continue to flex and the ankle dorsiflexes, the leg "shortens"
so that it can clear the ground.
LATERAL OBSERVATION
From the lateral note rhythm, symmetry, speed, and stride lengths of
cadence. Vertical excursion is best viewed from the side. Check if the
duration of the stance phase is the same bilaterally. As the patient
walks, note all deviations from normal gait. Normally, the head and
trunk are vertical, stride length is even, and the arms swing freely and
alternate with the leg swing.
Note the foot at heelstrike and pushoff. The foot is about at a right
angle to the leg and the knee is extended but not locked at heelstrike.
At pushoff, the foot is firmly flexed and the toes are hyperextended.
The foot easily clears the floor during the swing phase of the gait.
Displacement. The trunk should be vertical at stance. Observe the
degree of lurch during flexion, extension, and during the swing phase.
Note degree of hip, knee, and ankle flexion. If the head is carried far
forward, seek further evidence of atlanto-occipital fixation,
subluxation, costoclavicular or neurovascular syndrome, upper dorsal
lesion, or shoulder disorder. These malfunctions would also be suspect
if the head were titled to one side, but lateral carriage is found more
commonly in torticollis, in visual defects, and in primary or secondary
scoliosis.
Pathologic Postures. If pain is present, determine where and when
it is greatest. Check for trunk fixation in flexion or extension. Fixed
lordotic and kyphotic spines will be evident during both stance and
swing, but posterior pelvic tilts are difficult to observe. Shoulders
drooping forward may be an indication of cardiac dysfunction, lung or
pleural pathology, depression, or a dorsal lesion. Diabetics and those
suffering from cardiorenal disorders often have pot bellies. Due to the
lack of tone in the abdominal musculature, the viscera sag downward
which results in organ malposition and disturbed function
contributing to the problem.
ANTERIOR-POSTERIOR OBSERVATION
From the front and rear, note rhythm, symmetry, and speed of
cadence. Lateral motions are best viewed from the front or rear. As the
body advances, note smoothness of the body's vertical oscillation.
Pathology may express itself in increased vertical oscillation and
anterior to provide a thrust for the leg, the cause is most likely weak
quadriceps. If the hip is flexed excessively to bend the knee and thus
prevent the toe from scraping the floor as in a steppage gait, weak
ankle dorsiflexors are the usual cause. Failure to hyperextend the foot
during pushoff is a sign of arthrosis. Pushing off with the lateral side
of the front of the foot is usually seen in disorders involving the great
toe. A flat-footed calcaneal gait during pushoff is symptomatic of weak
gastrocnemius, soleus, and flexor hallucis longis muscles. The foot will
have trouble clearing the floor if the ankle dorsiflexors are weak or the
knee is unable to flex properly.
ANTALGIC GAITS
Guarded Limps. A limp may be a sign of disease, malfunction, or
both. It may also be in compensation to another condition such as a
sprained ankle, injured knee, old fracture malunion or hip surgery.
However, the majority of limps seen are those desribed as "guarded"
limps. Guarded limps frequently point to specific musculoskeletal
disorders. These limps are the result of the patient walking in a
manner that protects or relieves stress upon an area that would
otherwise be uncomfortable or painful. The term "antalgic position" is
that static posture assumed by the patient to produce the same pain
diminishing effect as does a guarded gait.
Midspinal and Bilateral Spinal Pain. When pain is in the midline of
the spine, the gait pattern is guarded, symmetrical, slow, with a short
stride and restricted trunk rotation and pelvic tilt. If paraspinal
muscle spasm is present, the patient will tend to lean backward
throughout the gait in compensation. However, if the irritation is
located at the posterior aspect of the spinal column (eg, articular
heelstrike, so that the patient will walk on the toes of the affected side.
This guarded gait minimizes quadriceps function and thus reduces
knee compression.
Ankle Pain. In any painful disorder of the ankle, ankle motion will be
guarded and the most comfortable position will be assumed. There is
little, if any, plantar flexion during footflat or heelstrike, or dorsiflexion
during heel-off. This will be compensated for by an exaggerated knee
flexion after heeloff and a restricted heel rise before toeoff. The patient
will reduce his base and shift his trunk so that more weight falls
directly over the joint during weight bearing.
Common Stance-Phase Problems. Most stance phase problems are
the result of pain and characterized by an antalgic gait wherein the
patient spends as little time on the affected extremity as possible. Gait
patterns vary according to the type and location of the disorder
present. A shoe problem should not be overlooked, as it is one of the
more common causes. Pain in a foot during midstance may be caused
by corns, calluses from a fallen transverse arch, rigid pes planus, a
plantar wart, bunion, subtalar arthritis, or poor-fitting shoes. Heelstrike will be eliminated, and toe walking will be seen, if a lesion is
present in the heel or posterior aspect of the foot. Lesions of the
forefoot such as metatarsal or phaangeal disorders are characterized
by heel walking, reduced pushoff, and an exaggerated forward hip
thrust and knee flexion in compensation. Sharp pain on pushoff is
often caused by corns between the toes or metatarsal callosities. In
longitudinal arch disorders, weight will be borne on the lateral plantar
surface during weight bearing. If chronic, excessive wear on the lateral
sole of the shoe will be noted.
Stroke is known to alter muscle stretch responses following a perturbation, but little is known
about the behavioural consequences of these altered feedback responses. Characterizing
impairments in people with stroke in their interactions with the external environment may lead to
better long term outcomes. This information can inform therapists about rehabilitation targets
and help subjects with stroke avoid injury when moving in the world.
Methods
In this study, we developed a postural perturbation task to quantity upper limb function of
subjects with subacute stroke (n=38) and non-disabled controls (n=74) to make rapid
corrective responses with the arm. Subjects were instructed to maintain their hand at a target
before and after a mechanical load was applied to the limb. Visual feedback of the hand was
removed for half of the trials at perturbation onset. A number of parameters quantified subject
performance, and impairment in performance was defined as outside the 95th percentile
performance of control subjects.
Results
Individual subjects with stroke showed increased postural instability (44%), delayed motor
responses (79%), delayed returns towards the spatial target (79%), and greater endpoint errors
(74%). Several subjects also showed impairments in the temporal coordination of the elbow and
shoulder joints when responding to the perturbation (47%). Interestingly, impairments in task
parameters were often found for both arms of individual subjects with stroke (up to 58% for
return time). Visual feedback did not improve performance on task parameters except for
decreasing endpoint error for all subjects. Significant correlations between task performance and
clinical measures were dependent on the arm assessed.
Conclusions
This study used a simple postural perturbation task to highlight that subjects with stroke
commonly have difficulties responding to mechanical disturbances that may have important
implications for their ability to perform daily activities.
Keywords: Stroke, Proprioception, Assessment, Perturbation, Upper limb, Robotics